SOAP Note Women's health /SOAP Note Women’s Health Elaborations

SOAP Note Women’s Health Patient Information: Initials A.P Age 31 Sex Female Race Caucasian Insurance Blue Cross Blue Shield S. Chief Complaint (CC): A.P. is a 31-year-old Caucasian female presented to the clinic with the chief complains of 5 years of the irregular menstrual cycle, pelvic pain that started about a year ago with increased intensity and length for about a month, and acute onset of burning on urination started about 2 weeks ago. A.P. reported to live with her boyfriend and is sexually active for last 5 years. HPI: A.P is a 31-year-old female presented with the long history of the irregular menstrual cycle, chronic pelvic pain, and new onset of burning urination. A. P. had her menarche at age 13 years of age and her menstrual cycle was regular. Since last 5 years, her menstrual cycle has been irregular. She reported having her cycle once every 2 to 4 month with heavy menstrual flow and dysmenorrhea. She was started on the oral contraceptive pill for her abnormal menstrual cycle, menorrhagia, and dysmenorrhea which she tried for about a year. It helped to regulate her cycle but she gained weight abruptly and had mood change so she decided to stop it. After she stopped taking birth control pill her symptoms came back. She hasn’t seen the OBGYN for 2 years. She also reported few episodes of a headache and nausea and had done multiple home pregnancy tests which have been negative. The last home pregnancy did four days ago was negative. She also reported having intermittent pain in the pelvic region which has been going on for about a year. She explains the pain as mild to moderate dull aching pain, rated 3-5 in the scale of 0-10, around the pelvic and lower abdomen, worsened during and after sex. The Hot top bath helps her to relax and relieve some of the symptoms. She reported to have increased frequency of pelvic pain and new onset of burning on urination for last 2 weeks which she is worried about possible infection or illness, th